Brief
Summary:
On May 28, 2009, Vladimir from Israel, who has suffered from
ALS, accompanied with the symptom of the weakness of the hands
for 1 year, was hospitalized in our hospital. He has achieved
much improvement after 51 days TCM treatment here. Compared with
before, his speaking was clearer and more fluent. The gripping
power of his hands increased. The slight muscular jumping of the
arms and prothorax completely
disappeared.
Record of Hospitalization
Name:
Vladimir Birthplace: Israel
Sex:
Male Profession: Businessman
Age:
69 Date
of Admission: May 28, 2009
Religion:
Muslim Date of
Record: May 28, 2009
Marital Status:
Married Onset Season: Summer
begins
Complainer:
The patient himself
First Medical Record
Date: May 28, 2009 Time:
1: 00 a. m.
Vladimir, a 69-year-old male, has suffered from ALS, accompanied
with the symptom of the weakness of the hands for 1 year. He was
hospitalized in our hospital at 1: 00 a. m. on May 28, 2009.
Essentials for Diagnosis:
1. The
patient has suffered from the symptom of the weakness of the
hands for 1 year.
2. Last
May, the patient began to feel the weakness of the hands without
obvious reasons, but he didn¡¯t pay much attention to this and
hadn¡¯t taken any examination and treatment. Then the condition
gradually became worse. In April 2009, he was given MRI
examination in the local hospital and was diagnosed with ALS.
The doctor told him there was no treatment for ALS except for
Rilutek capsules. Besides, he didn¡¯t take any treatment. So he
came to our hospital on May 28, 2009 for further treatment.
3. T
36.3¡æ,
R 20 times/minute, P 80 times/minute, BP 140/80mmHg.
4. He
grew normally with common nutrition. His mind was clear. He had
an expression of chronic illness and tiredness. His body was
cooperative with his mind.
5. No
thoracic deformity. Sound of breath was bilaterally normal on
auscultation. No sound of pleural friction. Heart border was
normal. Heart beat was 80 times/minute. Cardiac rhythm was
regular. No pathological murmurs on auscultation.
6. The patient felt the weakness of the hands, sometimes
accompanied with pains. His hands were delicate and the ability
to act was declining. The flexibility of the fingers was good.
The gripping power of the left hand was 10.2 kg and that of the
right hand was 9.2 kg. There was slight muscular jumping of the
arms and prothorax. The function of
his speaking declined. Sometimes he had the symptom of dry cough
when drinking water.
7. Accessory examination: None.
Diagnostic Basis:
TCM: The patient has suffered from the weakness of the hands for
1 year. He
felt the weakness of the hands, sometimes accompanied with
pains. His hands were delicate and the ability to act was
declining. The flexibility of the fingers was good. The gripping
power of the left hand was 10.2 kg and that of the right hand
was 9.2 kg. There was slight muscular jumping of the arms and
prothorax. The function of his
speaking declined. Sometimes he had the symptom of dry cough
when drinking water. His tongue was dark. His tongue coating was
yellow and slimy. His pulse was wiry, thready and slippery. The
patient was mainly characterized by limp, weak, and
emaciated limb. According to the symptoms of the tongue and
pulse, he was diagnosed with wilting pattern.
Western Medicine: The patient has
suffered from the weakness of the hands for 1 year. He
felt the weakness of the hands, sometimes accompanied with
pains. His hands were delicate and the ability to act was
declining. The gripping power of the left hand was 10.2 kg and
that of the right hand was 9.2 kg. There was slight muscular
jumping of the arms and prothorax.
The function of his speaking declined. Sometimes he had the
symptom of dry cough when drinking water. He was given
MRI examination in the local hospital and was diagnosed with ALS
in April 2009.
Diagnostic Differentiation:
TCM:
The patient¡¯s wilting pattern should be differentiated from
impediment pattern. Wilting pattern is characterized by limp,
weak, and emaciated limbs with the numbness of the muscles. But
the patient usually has no joint pains. On the contrary,
impediment pattern is generally characterized by joint pains. So
they are not difficult to be distinguished.
Western Medicine: ALS should be differentiated from tumor of
spinal cord, which is characterized by nerve root pains of the
upper limbs, but without extensive trembling of the muscle
bundles. Besides, there is disturbance of sensation and
obstruction of the subarachnoid cavity. The disease can be
diagnosed clearly by the examination of CT or MRI.
First Diagnosis:
TCM diagnosis: Wilting pattern
Symptom identification: qi vacuity and blood stasis, damp-heat
obstructing the channels and network vessels.
Western Medicine diagnosis: 1. ALS
2. Chronic
hyperplasia of prostate gland
Plans for treatment strategy and nursing:
1. Routine
care of traditional Chinese internal medicine.
2. Grade
II care.
3. Under
the care of a companion.
4. Low-fat
and high-protein diet.
5.
TCM treatment strategy: boost qi, quicken the blood circulation,
clear heat, dispel dampness and free the channels and network
vessels.
6. Herbal
tea: one dosage a day and drink twice.
7. Acupuncture
and massage: once a day.
8. Have
more medical examinations if necessary.
Date: May 28, 2009 Time:
9: 00 a. m.
The patient has suffered from the weakness of the hands for 1
year. Last May, he began to feel the weakness of the hands
without obvious reasons and his condition was gradually worse.
In April 2009, he was given MRI examination and was diagnosed
with ALS. Then he took Rilutek capsules for 1 month. Presently
the patient felt the weakness of the hands, sometimes
accompanied with pains. His hands were delicate and the ability
to act was declining. The function of
his speaking declined. Sometimes he had the symptom of dry cough
when drinking water. Besides, there was slight cough. He had the
history of chronic obstructive pulmonary disease and
hyperplasia of prostate gland. His mouth was dry and he drank
much water. There was slight muscular jumping of the arms and
prothorax. His weight reduced 5-8 kg
in the recent months. He was easy to be tired. His heart was ok.
His walking was normal. His urine was ok, but he had
constipation. There was no obvious muscular atrophy all over the
body. His BP was 140/80mmHg. The gripping power of the
left hand was 10.2 kg and that of the right hand was 9.2 kg. His
pulse was wiry, thready and slippery. His tongue was dark. His
tongue coating was yellow and slimy. According to the symptoms
of the tongue and pulse, Professor Yang believed that the
patient had suffered from wilting pattern due to qi vacuity and
blood stasis, damp-heat obstructing the channels and network
vessels. So the treatment strategy for him was to boost qi,
quicken the blood circulation, clear heat, dispel dampness and
free the channels and network vessels. The prescription was as
follows: baizhu (ovate atractylodes
root), chuanxiong (ligusticum root), etc. 5 dosages in total.
Date: May 29, 2009 Time:
9: 00 a. m.
The feedback of the examination was as follows: Blood R (£),
Urine R (£),
Stool R (£).
The function of the liver and kidneys as well as blood fat was
normal. The examination of
type-B ultrasonic showed that the echo of liver parenchyma
became thick. Doctor considered it as fatty liver. Besides, he
had cyst in the left kidney.
Date: May 31, 2009 Time:
9: 00 a. m.
There was slight improvement of the weakness of the hands. But
there was no obvious change of the muscular jumping. His sleep
was ok. His urine and stool were normal. His tongue was pale
red. His tongue coating was thin and yellow. His pulse was
thready and slippery. The former prescription was changed a
little. 5 dosages in total.
Date: Jun. 1, 2009 Time:
10: 00 a. m.
His speaking was clearer. The strength of the upper limbs
increased, but there was slight muscular jumping of the arms and
prothorax. There was discomfort in
the throat and he consciously felt there was phlegm. The
prescription was made a little change.
Date: Jun. 5, 2009 Time:
10: 00 a. m.
He felt the weakness all over the body and slight heavy sense.
The other condition was ok. Doctor thought it was due to his
diarrhea on Jun. 3 which had relation with dietary
irregularities. So the prescription was changed and the doctor
added some herbs to fortify the spleen and transform dampness. 5
dosages in total.
Date: Jun. 10, 2009 Time:
10: 00 a. m.
The strength increased and his speaking was clearer compared
with before. He didn¡¯t feel the heavy sense all over the body.
He had dry mouth, especially in the night. The prescription was
changed. 5 dosages in total.
Date: Jun. 15, 2009 Time:
9: 30 a. m.
Compared with before, his speaking was clearer. The gripping
power of the left hand was 12.2 kg and that of the right hand
was 9.7 kg. He felt aching pains on his shoulders. His sleep was
ok. His urine and stool were normal. Continue to take the same
prescription. 5 dosages in total.
Date: Jun. 20, 2009 Time:
9: 00 a. m.
His condition was stable. There was no obvious change. His sleep
was not good due to hot weather in the recent days. His pulse
was wiry and thready. His tongue was pale. His tongue coating
was thin and yellow. The prescription was the same as before. 4
dosages in total.
Date: Jun. 23. 2009 Time:
9: 00 a. m.
His condition was stable. His diet and sleep were normal. His
pronunciation was clear and
resonant. His sleep was ok. His urine
and stool were normal. He kept in good mood. His tongue was
slight moist, slippery and dark. His tongue coating was thin and
yellow. The prescription was as follows: chuanxiong (ligusticum
root), danggui (tangkuei), etc. 4 dosages in total.
Date: Jun. 30, 2009 Time:
9: 30 a. m.
His spirit and sleep were good. His urine and stool were normal.
Compared with before, his speaking was obviously clearer. The
strength of the hands increased. His tongue was pale with
slightly dark. His tongue coating was thin and yellow. Continue
to take the same prescription. 5 dosages in total.
Date: Jul. 5, 2009 Time:
10: 00 a. m.
His condition was stable. There was no obvious change. He was
easy to sweat. The other condition was normal. The prescription
was changed a little. 5 dosages in total.
Date: Jul. 10, 2009 Time:
10: 00 a. m.
The symptom of the weakness all over the body was improved.
There was obvious improvement of sweating. His speaking was
clear. His sleep was ok. His urine and stool were normal. The
prescription was made a little change on the basis of the
prescription on Jul. 5. 5 dosages in total.
Date: Jul. 11, 2009 Time:
10: 00 a. m.
His spirit and sleep were good. His urine and stool were normal.
The weakness all over the body and pronunciation were improved.
The doctor added fuxiaomai (light wheat grain) in the previous
prescription. 5 dosages in total.
Date: Jul. 20, 2009 Time:
10: 00 a. m.
The patient said his condition was good. His pronunciation was
resonant.
There was no weakness all over the body. His sleep was ok. His
urine and stool were normal. The prescription was the same as
before. 5 dosages in total.
Date: Jul. 25, 2009 Time:
10: 00 a. m.
The patient decided to leave the hospital tomorrow.
More ALS cases that we helped well:
Case-1
Case-2
Case-3 Case-4
Case-5
Case-6
Case-7
Case-8
Case-9
Case-10
Case-11
Case-12 Case-13
Case-14 Case-15
Case-16 Case-17
Case-18 Case-19
Case-20 Case-21
Case-22 Case-23 Case-24
Case-25
Case-26 Case-27
Case-28
Case-29
Case-30 Case-31
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